Social Determinants of Health and Community Based Organizations
Subcommittee Meeting #6
December 16, 2015
2
Agenda
1. CBO Recommendations
a. Revisions to Existing Recommendations
b. New Recommendations
2. SDH Recommendations
a. Revisions to Existing Recommendations
b. New Recommendations
3. Final Step
3
1. CBO Recommendations
4
Current CBO Recommendations
The subcommittee workgroups created one recommendation and revised five since the last meeting. Please
see the table below. Grey highlight indicates a revision and orange indicates a new recommendation. The
recommendations are further outlined on slides 5-10.
No.
Recommendations
Change
25
Develop educational materials on VBP for CBOs, providers/provider networks, and MCOs
Yes
26
Link member SDH information to the appropriate CBO through bidirectional system
Yes
27
Create a “Design and Consultation team” to support CBOs
Yes
28
Develop criteria for CBOs to help determine readiness for VBP arrangements
No
29
State funding should be made available to CBOs
New
30
Encourage the integration of community-based care teams into the clinical care setting
Yes
31
VBP providers/provider networks should contract with a minimum of one CBO
Yes
5
Recommendation #25: Develop Educational Materials
Revised
Current Recommendation:
The State or a third party should develop educational materials on VBP that focuses on both CBOs’ part in the system and guidance on the value proposition CBOs should expect to provide when contracting with providers/provider networks.
Proposed Recommendation:
The State and/or a third party should develop educational materials on VBP that focuses on both CBOs’ part in the system
and guidance on the value proposition CBOs should expect to provide when contracting with providers/provider networks and
MCOs. Additionally, the State should provide technical assistance for the providers/provider networks/MCOs (nonCBO) contracting entities on how to work effectively with CBOs.
The State: Recommendation
Description:
This recommendation aims to achieve several objectives. First, it will explain the changes that CBOs can expect to see from
VBP and managed care (e.g. healthcare delivery changes, payment structure changes, more focus on preventive medicine).
Second, it should provide guidance on how an organization could self-assess its readiness to overcome potential challenges.
Third, educational materials should outline interventions (program initiatives) a CBO could consider as part of its “value
proposition” to potential payers (e.g. fees for the CBOs services, outcome measurements, possible savings) as well as
methods to assess contracting opportunities. Basic educational information could be communicated over several mediums
(e.g. webinars, forums, a VBP CBO page on the DOH website, frequently asked questions, readiness checklist). Fourth, providers/provider networks/MCOs should be educated about potential CBO partners, how to work with CBOs and what benefits they offer.
Note: For your reference, please refer to the Draft Recommendations document (pg. 17) for the complete current recommendation and description.
6
Recommendation #26: Link Member SDH Information to CBOs
Revised
Current Recommendation:
The State should create a workgroup to determine the possibility of, or options for, developing a user-friendly system for providers to
link members’ SDH(s) to the appropriate CBO(s). The providers/provider networks will be responsible for implementing the system
within their networks.
Proposed Recommendation:
The State should create a workgroup to determine the possibility of, or options for, developing a user-friendly, bidirectional system
that enhances communication between providers/provider networks and CBOs to better address members’ SDH needs.
Once the system has been developed, the State should ensure providers/provider networks implement the system within
their networks. The providers/provider networks should collaborate with CBOs to ensure the correct and relevant SDH
information is collected.
The State: Recommendation
Description:
The workgroup should not only research what is needed in this new system but also determine if there are systems currently available
that could provide some of the needed information in the interim. Consideration should be given to a system that meets some of the
criteria and has the ability to be implemented at low cost and within a short timeframe, while an ideal system is being created.
Linking members to the proper resources, primarily local CBOs, is necessary to better address SDH. This proposed system should
interface with existing EMRs and provide data on both a member’s assessment and the provider’s success of linking the member to
an organization that meets the member’s needs. Further, CBOs will need to be heavily involved in the linking of SDH to CBOs to
ensure the system covers all of the services necessary.
The State could explore the use of the Regional Health Information Organizations (RHIO) and State Health Information Network of New York (SHIN-NY) as the data repository for CBOS to share data where SDH can be measured against DSRIP
goals. The local Offices for the Aging could be consulted about the data they collect through their various CBO agencies and how that data can be shared to determine their impact on SDH and DSRIP goals.
Note: For your reference, please refer to the Draft Recommendations document (pg. 17) for the complete current recommendation and description.
7
Recommendation #27: Create a Design and Consultation Team
to Support CBOs
Revised
Current Recommendation:
The State should create a “design and consultation team” comprised of experts from relevant State agencies and advocacy
and stakeholder groups to provide focused consultation and support as requested by CBOs who are either involved or
considering involvement in VBP.
Proposed Recommendation:
The State should create a “design and consultation team” comprised of experts from relevant State agencies and advocacy
and stakeholder groups to provide focused consultation and support, at no cost, as requested by CBOs who are either
involved or considering involvement in VBP.
The State: Recommendation
Description:
The goal of the “design and consultation team” will be to prepare CBOs with the information and support needed to create
effective partnerships with health care entities (e.g. health plans, providers, provider networks). The team of experts should
include individuals with knowledge in VBP, finance, operations, legal, and contracting, to provide the appropriate support to
CBOs through structured management, education and technical assistance.
Note: For your reference, please refer to the Draft Recommendations document (pg. 18) for the complete current recommendation and description.
8
Recommendation #29: State funding should be made available
to CBOs
New
Proposed Recommendation: State funding should be made available to CBOs to help prepare them for their participation in
VBP arrangements.
The State: Recommendation
Description:
CBOs will need funding for infrastructure development, to include IT systems (e.g. ability to do measurement and data
collection to demonstrate their value), contracted services (e.g. fiscal and legal expertise), and other areas needing
assistance. In addition, the State should explore mechanisms for how it could assist and support CBOs if payment or cash
flow issues arise.
Note: For your reference, please refer to the Draft Recommendations document (pg.19) for the complete current recommendation and description.
9
Recommendation #30: Encourage the integration of
community-based care teams into the clinical care setting
Revised
Current Recommendation:
The State should require integration of CBO Case Managers in the acute care setting. Proposed Recommendation:
The State should encourage integration of community-based care teams into the clinical care setting.
The State: Recommendation
Description:
Given the vast array of community based services, acute care Case Managers may not fully understand the ever-changing
services and admission criteria of CBOs. Integrating community-based care teams from CBOs into the clinical care setting
will improve efficiency in finding and transferring members to lower levels of care where they can receive the treatment
needed and may ultimately decrease costs. The community-based care teams should provide training to the non-CBO
Case Managers to strengthen the Case Management Department.
Note: For your reference, please refer to the Draft Recommendations document (pg. 20) for the complete current recommendation and description.
10
Recommendation #31: Contracting with a Minimum of one
CBO
Revised
Current Recommendation:
Every VBP contracting entity (e.g. providers, provider networks) will contract and engage with a minimum of one CBO in a
way that the CBO considers meaningful.
Proposed Recommendation:
Every VBP contracting entity (e.g. providers, provider networks) will contract and engage with a minimum of one CBO.
VBP Level 1 Providers: Guideline; VBP Level 2 or 3 Providers: Guideline; The State: Recommendation
Description:
Every VBP contracting entity seeking to decrease costs of healthcare and improve overall health in the community
should contract and engage with a minimum of one CBO. Many CBOs have years of experience improving SDH. This
expert understanding of community needs, coupled with support and clinical expertise of a provider/provider
network, could make a significant positive impact on population health and generate savings for the entities
involved. Providers/Provider networks should partner with organizations that have objectives aligning with their
own, the community needs, and member goals. The CBO should work with the providers/provider networks to
deliver interventions that support SDH and advance DSRIP goals. After a period of two to three years, the State
should create a process, which would include an independent retrospective review of the role of the CBO, to
determine if the VBP providers are adequately leveraging community based resources. The review would also
identify best practices and determine if further guidance or technical assistance is needed to maximize utilization of
community resources.
Note: For your reference, please refer to the Draft Recommendations document (pg. 20) for the complete current recommendation and description.
11
2. SDH Recommendations
12
Current SDH Recommendations
The subcommittee revised seven and created four new recommendations since the last meeting. Please see the table
below and on the following slide. Grey highlight indicates a revision and orange indicates a new recommendation. The
recommendations are further outlined on slides 14-25.
No.
Recommendations
Change
1
Implement interventions on a minimum of one SDH
No
2
SDs to address should include both needs and goals of individuals and the community
Yes
3
Invest in ameliorating an SDH at the community level
Yes
4
Incentivize and reward providers for taking on a member and community-level SDH
No
5
Maintain a robust catalogue of resources to connect individuals to community resources
Yes
6
Employ a workforce that reflects and is culturally sensitive to the community served
Yes
7
Create a data system and dashboard that displays cultural competence performance measures
New
8
Form a taskforce of experts focused on children and adolescents in the context of VBP
No
9
Utilize an assessment tool to measure and report on SDs that affect members
No
10
Set up a system to track what interventions are successful and how they are measured
Yes
11
Track discrete outcomes of interventions and use a CQI model for enhancing them
No
12
Incorporate SDH into QARR Measures
No
13
Form a taskforce to identify standard SDH data sources to include in acuity calculation
New
13
Current SDH Recommendations
The subcommittee revised seven and created four new recommendations since the last meeting. Please see the table
below and on the previous slide. Grey highlight indicates a revision and orange indicates a new recommendation. The
recommendations are further outlined on slides 14-25.
No.
Recommendations
Change
14
Create a standard set of SDH measures
New
15
Require Medicaid providers, MCOs, and the State to collect standardized housing stability data
No
16
Provider, provider networks and MCOs should coordinate with Continuum of Care (COC) entities, where they exist,
when considering investments to expand housing resources
No
17
New York City, the State, and other involved localities should update the NY/NY agreements to give priority to homeless
persons who meet HARP eligibility criteria without regard for specific diagnoses or other criteria
Yes
18
Submit a NYS waiver application to CMS that tracks the June 26, 2015 CMCS Information Bulletin
No
19
Leverage the Medicaid Reform Team housing work group money to advance a VBP-focused action plan
No
20
Submit a waiver application that challenges the restrictions on rent in the context of VBP
Yes
21
Provider networks could participate in a co-investing model
No
22
Provider networks could participate in innovative contracting
No
23
Provider networks could invest in one or more social impact bonds
No
24
The State should assess economic development investments
New
14
Recommendation #2: Member and Community Goals
Revised
Current Recommendation:
The SD(s) chosen to be addressed by providers/provider networks should be based on the results of an assessment of individual members,
their health goals and the impact of SDs on their health outcomes, as well as an assessment of community needs and resources.
VBP Level 1 Providers: Guideline; VBP Level 2 or 3 Providers/Provider Networks: Standard
Proposed Recommendation:
The SD interventions selected by providers/provider networks should be based on the results of an SDH screening of individual
members; member health goals; and the impact of SDs on their health outcomes; as well as an assessment of community needs and
resources.
Description:
It is important to recognize that no one SD can necessarily be prioritized over others. Rather, the priorities will vary based on personal
circumstances, including health factors. For example, if a person is homeless, housing is likely to be the top priority but not necessarily that
person’s only need. Indeed, many SDs are both co-occurring and co-factors in other SDs. Thus, prioritizing which SDs a VBP network
should address should depend upon the results of an SDH screening of individual members; member health goals; and the impact of
SDs on their health outcomes. In addition to the individual member’s screening, there should be an assessment of community needs and
resources. The DSRIP community needs assessment could provide a starting point for a more detailed assessment of the community
cared for by the providers/provider networks. Further information can be gained by completing a focused needs assessment by the
particular providers/provider networks with emphasis on the chronic illness(es) or populations chosen in their VBP agreement. The decision
of which SD(s) to address should be based on both the members’ goals and the community needs of the provider’s members. The
prioritization must happen with a flexible approach and at a local level, balancing both individual needs with overall population health.
Eighteen specific SDs have been identified under five key domains of SDH and are believed to have the greatest impact on health
outcomes for Medicaid beneficiaries (see Appendix 1: SDH Interventions Menu).
Note: For your reference, please refer to the Draft Recommendations document (pg. 3) for the complete current recommendation and description.
15
Recommendation #3: Invest in ameliorating an SDH at the community level
Revised
Current Recommendation:
Providers/provider networks and MCOs should invest in ameliorating a SDH at the community level.
VBP Level 1 Providers: Guideline; VBP Level 2 or 3 Providers/Provider Networks: Standard; MCOs: Standard
Proposed Recommendation:
Providers/provider networks and MCOs should invest in ameliorating a SDH at the community level employing a community
participatory process.
VBP Level 1 Providers: Guideline; VBP Level 2 or 3 Providers/Provider Networks: Standard; MCOs: Standard
Description:
Providers/provider networks and MCOs should invest in effective interventions that have a meaningful impact on the overall
population health and the overall wellbeing of the community in which it serves. The nature of the interventions(s) should be
negotiated between the VBP contractor and MCO, taking into account population health and preventive health needs identified by the
community. This community participation will lead to a more culturally competent, effective intervention. A participatory
approach is one in which everyone who has a stake in the intervention has a voice, either in person or by representation.
Provider/provider networks and MCOs may wish to collaborate with CBOs to support, develop, and broaden their reach to more
communities. To that end, networks should consider larger partnerships and advocate for systemic improvements that might not be
easily quantified on the individual member level immediately or in the short-term. For example, participating in a campaign to make
fresh produce available in a “food desert” would not only have an impact on members with specific nutritional deficits, but would also
contribute to overall population health and community well-being. The same can be said for participation in efforts to improve air
quality, housing stock and many other SDs that contribute to overall population health. Ultimately the goal should be to track the
impact of interventions, not just on an individual level, but on a population level.
Note: For your reference, please refer to the Draft Recommendations document (pg. 4) for the complete current recommendation and description.
16
Recommendation #5: Maintain a robust catalogue of resources
to connect individuals to community resources
Revised
Current Recommendation:
Providers/provider networks should maintain a robust catalogue of resources in order to connect individuals to community
resources that are expected to address SDH.
VBP Level 1 Providers: Guideline; VBP Level 2 or 3 Providers/Provider Networks: Guideline
Proposed Recommendation:
Providers/provider networks should maintain a robust catalogue of resources in order to connect individuals to community
resources that are expected to address SDH.
VBP Level 1 Providers: Guideline; VBP Level 2 or 3 Providers/Provider Networks: Guideline; The State: Recommendation
Description:
By creating a catalogue or living library of resources, providers can quickly and easily refer members to appropriate and
effective community based organizations. Members can also take a more active role in their healthcare if they are provided
information on community resources that they can use to better improve their quality of life and health outcomes. The
providers/provider networks should maintain an up-to-date, robust catalogue of resources that should align with the
information from the assessment tool and the SDH Interventions Menu (Appendix 1). In the longer term, the State,
together with payors, providers, community-based organizations, and municipalities, should create a usable,
universal, electronically supported system for assessing individual patients’ needs and providing automatic links to
vetted resources to address patients’ SDH at the individual level.
Note: For your reference, please refer to the Draft Recommendations document (pg. 5) for the complete current recommendation and description.
17
Recommendation #6: Employ a workforce that reflects and is
culturally sensitive to the community served
Revised
Current Recommendation:
Providers/provider networks should employ a workforce that reflects and is culturally sensitive to the community served.
VBP Level 1 Providers: Guideline; VBP Level 2 or 3 Providers/Provider Networks: Guideline
Proposed Recommendation:
Providers/provider networks should employ a culturally competent and diverse workforce that reflects the community
served.
VBP Level 1 Providers: Guideline; VBP Level 2 or 3 Providers/Provider Networks: Guideline
Description:
Cultural Competence is a broad term, however there are several widely-accepted definitions that can be used in the
VBP context (e.g. National CLAS Standards). Lack of access to culturally competent staff has been identified as a barrier
to better health. It is critical for providers/provider networks to understand cultural competence and incorporate
accepted cultural competence standards in their practice. To better serve the community, and provide the best
healthcare, providers/provider networks should use data from demographic reports and hire staff that reflect, and is
culturally sensitive to the community served.
The SDH Interventions Menu (Appendix 1) includes recommended interventions for this SD.
Note: For your reference, please refer to the Draft Recommendations document (pg. 5) for the complete current recommendation and description.
18
Recommendation #7: Create a data system and dashboard that
displays cultural competence performance measures
New
Proposed Recommendation:
The State should create a data system and dashboard that displays providers/provider networks’ cultural competence
performance measures. MCOs should monitor and report on outcomes based on race, ethnicity, disability, sexual orientation,
etc.
MCOs: Guideline; The State: Recommendation
Description:
Due to it’s length, the description is on the next slide.
Note: For your reference, please refer to the Draft Recommendations document (pg. 6) for the complete current recommendation and description.
19
Recommendation #7 continued
New
Description:
Performance metrics and dashboards can be used to define and communicate strategic objectives tailored to individuals and
the organizations where they receive services. Establishing goals, measuring progress, rewarding achievement and
displaying results in a way that is accessible and transparent can accelerate change and drive positive outcomes.
The State should create a data system and dashboard that encapsulates key performance metrics in a layered and visual
information delivery system, allowing users to identify disparities in health and health care and to measure the effectiveness of
interventions and strategies aimed at achieving equitable outcome for population being served.
Steps could include:
• Use available Medicaid data to construct performance metrics where appropriate, including the ability to view metric by
race, ethnicity, disability, sexual orientation, etc.
• Work with the Office of Minority Health and community stakeholders to further define performance goal and identify performance measures to tracked
• Join multiple data sources, where feasible to better describe populations and understand outcomes
• Use measures to track disparities in a dashboard format, such as web-based provider report stratified by demographic
variables
• Track performance, examine trends, make comparisons, and identify strong performers
• DOH will incentivize provider based on improved CC score
Additionally, MCOs should monitor outcomes based on race, ethnicity, disability, sexual orientation, etc. to inform negotiations
regarding performance metrics.
Note: For your reference, please refer to the Draft Recommendations document (pg. 6) for the complete current recommendation and description.
20
Recommendation #10: Set up a system to track what
interventions are successful and how they are measured
Revised
Current Recommendation:
Set up a system to track what interventions are successful and how they are measured.
The State: Recommendation
Proposed Recommendation:
The State should design and implement a system that aims to track what interventions are successful and how they are
measured. This should include, but not be limited to, systematically collecting and publicly reporting on member
experience with any service, whether from a CBO, hospital, behavioral health provider or primary care practice.
Members need this information to inform their own decisions and payment reform needs this level of transparency in
order to drive change and inform future contracting.
The State: Recommendation
Description:
The description was not changed.
Note: For your reference, please refer to the Draft Recommendations document (pg. 8) for the complete current recommendation and description.
21
Recommendation #13: Taskforce to identify standard SDH
data sources to include in acuity calculation
New
Proposed Recommendation:
The State should form a taskforce to identify standard data sources and points that can be utilized to provide a consistent and
reliable SD adjustment to the member acuity calculation prior to attribution, and establish an adjusted acuity calculation which
takes SDs into consideration when establishing member acuity.
The State: Recommendation
Description:
Given the central role of member acuity to VBP arrangements, and the fact that acuity calculations by the state are limited to
claims data and do not include an assessment of non-clinical SDs, a taskforce should be established to identify standard data
sources and points that can be utilized to provide a consistent and reliable SD adjustment to the member acuity calculation
prior to attribution. Data may include history of incarceration (Corrections), housing status, and other SES indicators (TANF,
etc.) that can be collected by the state. Following the establishment of standard collectable data points, the acuity calculation
should be adjusted. This process should be transparent throughout and include multiple opportunities for community
discussion and review.
Note: For your reference, please refer to the Draft Recommendations document (pg. 10) for the complete current recommendation and description.
22
Recommendation #14: Create a standard set of SDH measures
New
Proposed Recommendation:
The State should develop a standard set of measures for SDH that can be added to existing data collection and electronic
health record systems.
The State: Recommendation
Description:
A standard set of measures for SDH is important for reporting baseline data and outcomes, recognizing trends, and identifying
best practices in care. The State could leverage existing systems that measure SDH, such as the Statewide Planning and
Research Cooperative System (SPARCS) Health Data Query System. Medicaid claims data could also be used in the
development of the standard measures.
Note: For your reference, please refer to the Draft Recommendations document (pg. 10) for the complete current recommendation and description.
23
Recommendation #17: Housing – NY/NY Agreements
Revised
Current Recommendation:
New York City, the State, and other involved localities should update the NY/NY Agreements to give priority to homeless persons
who meet HARP eligibility criteria without regard for specific diagnoses or other criteria. For units that do not include HUD capital
or operating dollars, the definition of “homeless” should be modified to include persons who are presently in institutional or
confined settings so they are considered for housing before discharge.
New York City, the State, and other involved localities: Recommendation
Proposed Recommendation:
New York City, the State, and other involved localities should update the NY/NY Agreements to give priority to homeless persons
who meet Health and Recovery Plan (HARP) eligibility criteria or other serious supportive housing needs without regard for
specific diagnoses or other criteria. The definition of “homeless” should be modified (for units that do not receive US
Department of Housing and Urban Development (HUD) capital or operating dollars) to include persons who are presently
in institutional or confined settings.
New York City, the State, and other involved localities: Recommendation
Description:
Currently, the NY/NY Agreements attach units to specific agencies, such as OMH, OASAS and HASA, and attach
additional criteria such as length of homelessness, creating an “obstacle course” for persons seeking
housing. Because NY/NY uses the HUD definition of homelessness, persons leaving incarceration and other
institutional settings are completely precluded from this program. New York City, the State, and other involved localities
should amend the NY/NY Agreements so that those members who also have chronic conditions that require supportive
housing who are facing homelessness are given priority for supportive housing regardless of type of condition or other
criteria. Additionally, the definition of “homeless” used in the NY/NY Agreements should be expanded to include those persons
leaving institutional settings so they are considered for housing prior to discharge.
Note: For your reference, please refer to the Draft Recommendations document (pg. 12) for the complete current recommendation and description.
24
Recommendation #20: Submit a Waiver Application to
Challenge Restrictions
Revised
Current Recommendation: The State should submit a waiver application that challenges the restrictions on rent in the
context of VBP.
The State: Recommendation
Proposed Recommendation:
The State should submit a waiver application that challenges the restrictions on rent and home modifications in the context
of VBP.
The State: Recommendation
Description:
The description was not changed.
Note: For your reference, please refer to the Draft Recommendations document (pg. 13) for the complete current recommendation and description.
25
Recommendation #24: Assess Economic Development
Investments
New
Proposed Recommendation:
The State should assess economic development investments
The State: Recommendation
Description:
Community conditions’ impact on residents’ health is well documented. The State should assess economic development
investments for their impact on SDH and require that Regional Economic Development Councils undertake the same
assessment. The Rochester-Monroe County Anti-Poverty Initiative is a current example of how this type of assessment may
lead to investments that directly target poverty, poor housing stock and other drivers of SDH. The State of New York is
significantly investing in improving the economic development climate in specific regions and across the state. The Upstate
Revitalization Initiative (https://www.ny.gov/sites/ny.gov/files/atoms/files/2015UpstateRevitalizationInitiative_FINAL1.pdf), for
example, identifies Medicaid Redesign as a State initiative that can be leveraged to enhance economic development
investments.
Note: For your reference, please refer to the Draft Recommendations document (pg. 16) for the complete current recommendation and description.
26
3. Final Step
27
Final Step
The five Subcommittees’ final recommendations will be consolidated into a Recommendations
Report that will be submitted to the VBP Workgroup and incorporated in the roadmap.
Thank you for all of your help and support!
Subcommittee Co-chairs
Charles King [email protected]
Kate Breslin [email protected]